HomeMy WebLinkAbout0567A WORKERS'COMPENSATIONDECLARATION qpp�.ICATlO1� FOR PERMIT �
I he�44y n{firm that�I have a certificate of consenl to self
ic:�re,or a cerlifimie of Workers'Compensafion Insurance,
or a certified copy ihereof(Sec.3800,Lab.C.) 76A364C HEATING - VENTILATING - AIR� CONDITIONING
CE-818(REV.10/81) �
P❑olity No. Company .
Certified copy is hereby f�mished. COUNTY OF LOS ANGELES BUILDING AND SAfETY
� 'Certified copy is filed wifh ihe county building tospeo- POR APPLIGANT TO FILL IN BUILOiNG �
lion deportment.
�PRINT OR NPE ONLV) ADDRE55
Ovle Applicont IOCALITV
NO. TYPE OF APMIANCE OR EQUIPMENT fEE
CERTIFICATE Of EXEMPTtON FROM WORKERS' NEAkEST
COMPENSATION INSURANCE CROSS ST.
(Tht���c11on nesd nof 6e compfeNd if the wark involred by Ag50RPTION UNIT,BTU DISTRICi NO. PROCESSE�BY
the pern�i}is fer ene hundrod dolla�s(5100)or leec.) p�R HANDLING UNIT,CFM
1 certify ihat in�he performante oi tha wo�k 4or which this �a �9
permit is issued,I shall not employ ori erson i any manner
so as to become wbject to the Work 'Co p sotion Lows. BOILER,BTU APPROVAlS - DAiE INSPECTOR'S SIGNANRE
Do1���pplimnf COMGRESSOR,8TU ROUGH —
� NO�CE TO APPLICANT: If, afte oki g his eiY icate of VENTiLATION SYSIEM FMAL
� Exemp�ion, you should become subject to the orkers' �
Compensotion provisions of the Lobor Code,you mus�forfh- EVAPORATIVE COOtER VAIIDATION
wi�h comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GRAVITV
. LICENSED CONTRACTORS DECIARATION � F�oo2 aiu
I hereby affirm ihot I am licensed under provisions of Chapfer 9 HEATER: SUSPEN�ED UNIT_
�(commencing wilh Seciion 7000)of Division 3 of the Business � Wl+ll
and Professions Code,and my license is in f�ll force ond effect. � �
� � �
Litense Number Lic.Class � � � V
OG
Comroctor Date �
❑ I am ezemp�under Sec. �
u
Plan cfieck fee a
B.BP.C.ior this reason� NI
- PfRMIT ISSUfNG FEE� (� �
Date: .
Sgnatu�e TOTAL FEE
OWNER-BUILDER DECIARATION 7LAN CHECK APPLICANT
I hereby affirm that I am e�empt from�he Contractoi s Licensa �
law for�he following reason(Settion 7031.5,Business and NAnnE
�Vrof ssions Code):
W as owner of the property, or my empioyees with ADDRE55 �
ages as iheir sole compensation,will do the work and CITY TEI.NO.
the structure is not in�ended ar offered for sale(Seciion
7044,Business and Prafessions Code). �
O�NNER O$�7 A
❑ I,as owner of the property,am exclusively conhatting 1 �
with lirensed wnlmctors to construc�the project(Sec- MAa
tion 7044,Business and Professions Code). AO�RE55 .�+• • • • •8
CONSTRUCTION LENDING AGENCY ��Ty iEL tv0. Y I • ��Z�L 5
I hereby affirm tha�ihere is a consnuOion lending agency for ' ► • p y L*�,2 Jr�
the performonce of the work fo.which this permii is issued CONTRACiOR . O Q� V�S rI
(Sec.3097,Civ.C.). � .
ADDRE55
Lender's Name
CIN TEL ND.
Lender's Address
STATE �IC.
I certify ihal I have read ihis applicalion ond sfate lhot fhe LICENSE NO. CWSS
above inform ion is correct I ag�ee to comply with oll County
ordinances d Sta e ws elating ta building construction,
and h re autho z r senta�'rves of this County fo eMer
upo rh bove- e ' , property for inspection purposes. SEE REVfRSE FOR EXPLANATORY LANGUAGE
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